The Mentor's Corner - Winter, 2002
Jessica Rice asks:
I was hoping to get some feedback from some more experienced graduate students and psychologists aboutthe balancing act I’m about to begin.This fall will begin my second year in my terminal masters’ program. I will be doing my first clinicalpracticum, starting work on my thesis, teaching a course in general psychology, and taking a graduatelevel physiological psychology class. I’ve recently realized just how busy my life is going to become inthe next month. I guess I had been in a state of denial before now. I’m not quite sure how I’m goingto handle everything, much less succeed. I want to do well as a practicum student, have a good thesis, dowell in my physio course, and be a competent teacher. I just hope I’m not asking too much.I would greatly appreciate any advice or feedback I can get, especially from anyone who has been in a similar position and somehow made it through! Thanks so much.
Victor Ronis-Tobin responds:
Hi Jessica, You have my deepest sympathy. There’s so much you have to do and even more stuff you want to do because it’s interesting. You also have to balance some sort of income with all these academic and clinical requirements. I’ve just finished the second year of my program and it was hell. I had a 20 hour job, two externships and work on a thesis. In the middle of all this we had to move. The second year of your program is a year of growth and huge demand of resources, but it’s doable. What helped me was the support of friends in my program in homework and assignments. In clinical work you’re not expected to do everything at once. Teaching seems to be the hardest to pull off because you’re flying solo, but you can borrow notes from people who taught this class before, and use visual aids and such. What also helped was to do the necessary and worry about the next step when it comes. Good luck
Steve Wong adds:
Hi Jessica, I’m a fourth year graduate student in clinical psychology and I have done all of the things that you are planning to do this fall (although not all at the same time). I wish I could give you a different answer, but what you are accomplishing is going to be difficult (although not impossible). In my experience I found that the first clinical practicum and first teaching of a class (are you doing everything yourself? i.e. grading, coming up with lectures, etc.) are fairly stressful experiences, and they sap a lot of mental/emotional resources (which sometimes can be worse that just taking up time).The best thing to do is prepare yourself in every way that you can think of before the semester starts, so that you don’t spend the first 2 weeks in shock over your responsibilities and falling behind. I would definitely talk to other students who have taught the class. Can you borrow their notes? What tips do they have for you? You can do a lot of preparations for the class week by week. Don’t feel like everything has to be set in stone before the semester starts.I would also talk to other students about what the practicum is like so that you can mentally prepare yourself for that as well. What is your supervisor like? What types of things does he/she expect for supervision (tapes? transcripts?)? Get all of these details in your head so that you are already mentally “in a groove” when the semester starts.And remember. It’s only one year of your life. It may suck, but you have had many before and will have many after. You can do it. Good luck!
Joanne Festa adds:
Your schedule does sound daunting but it is doable. The key is organization and scheduling. Map out the whole semester, put in deadlines, and schedule work for each step toward meeting each deadline. Just getting the schedule together will help reduce the anxiety about meeting your obligations. Don’t fret; it can be done. Good luck
Kate Young shares:
Hello everyone, I am amazed when I hear how much so many people on this list are doing. I have to say that I’ve done my times of being extra-busy (last year it was my pre-doc internship, a toddler for whom I’m the primary care at home, a husband, applying for post-docs, and finishing and defending my thesis; and this year doing my post-doc, applying for jobs, studying for the EPPP, and still with child and husband care and attention issues), but I’ve come to a point in my life where I decided I have to slow down. What motivated me to change were two tragic experiences in January: a miscarriage, and the suicide of a friend of mine. These events made me stop in my tracks and really question the illusions of control and endless time and health I was working under. I also had to examine the possible impact my level of stress had on my body and my reproductive health. After a lot of reflection I decided not to keep myself in the running for the full-time (plus commute) college mental health job that I had always wanted. It was very scary to make this shift, especially in the beginning. I had to open up to the possibility that I may not have as much financial security or collegiality as the job would have offered, or the opportunity to use all the skills that I’ve worked so hard to gain and love to use in helping others. But after some thought and consultation with my supervisors, friends, mentors, and husband, I was able to take the plunge and decided to allow myself a less stressful working life, particularly to work 3-4 days per week rather than 5 once my post doc in done at the end of August this year. Then I was fortunate enough to find someone who was willing to take me on as a psychological assistant in the fall so that I can work part time in a private practice until I get licensed and can work on my own. As I’ve gotten over the fear of the unknown, I’ve found that I’m very excited about this opportunity, one which I had never held as my first choice of how I would be as a professional in this field. I know that I have more support in this change than many people would because although we are in debt financially (my and my husband’s education and having to use credit cards to get by many months in the past few years) it is to the point now that my husband is able to support us on his salary. Paying of the debt and building up savings will take time, but I expect that are doable eventually. I guess what I want to offer is three fold: First, our mental and physical health and our ability to work are truly fragile gifts; gifts that can be lost if we do not take care of ourselves. Second, the treadmill to success and the high goals for achievement that we have are NOT the only goals, or the only measure of a successful and fulfilling life. Finally, we need to have faith that as one door closes, another opens, and although it may not be apparent where that other door even is at first, or what it means, if we are patient and open and can manage our fear, we will discover what life/God/our destiny has in store for us. Thanks for listening.
Anne Goodnow adds:
Kate, thank you very much for your posting to the mentors list. I’m glad you sent it because I feel that I benefited very much from reading it. I too am finishing up my postdoc, preparing to take the EPPP, and making important decisions about my future. I have asked myself endless questions about the value of life and how I want to focus my energy. I am at the precipice of getting married, having children, buying a home, etc. I want to have the presence and internal serenity to be able to fully enjoy the things that I have sacrificed for until this point in my life. I’ve often wondered if I’m just “lazy” because I would prefer to only work 3-4 days per week, despite the financial consequences. I appreciate your perspective and feel a bit validated by our shared struggle to attain balanced, meaningful lives. I wish you the very best in your future pursuits.To those on the list who are in the midst of graduate school and clinical training experiences, I sympathize with your struggle. All of the feedback so far regarding goal setting and time management has been excellent and will very likely assist you in your balancing act. In the end, if you still feel overburdened, wiped out, and emotionally/physically unhealthy, please know that it is a wise and brave thing to set limits, say “no”, and put things off if it helps you to practice good self-advocacy and self-love. With fond regards.
Jeff Barnett contributes:
I am greatly appreciative of Jessica’s great question about the balancing act and the many wonderful and personal responses shared thus far. There really is a great collective wisdom being shared on this list.
Thank you all. I would also like to share my own perspectives on this important issue. First, I have a supportive wife who allows me the luxury of participating in my many professional activities that I enjoy so much. Without her support, I would not be able to accomplish nearly so much. I also find that effective time management is still very important. When I start feeling overwhelmed by how much I need to do and how little time there seems to be I find that I must stop thinking about this. I just get to work and keep moving forward until I’m caught up. I also find that I’ve becomeincreasingly efficient over the years, so I can accomplish more in a shorter amount of time. And, as I keep practicing it, I’m learning to say the word ‘no.’ I’m not so good at this yet, but I’m still working on it. Sometimes we just need to say no to things, even when they seem like great opportunities. There will be other opportunities in the future. I also find that I must keep things in balance for me. A certain combination of ever changing activities seems to work for me so I don’t get burned out. I also must make sure I find time for self-care, like enough sleep and regular exercise. Perhaps most importantly, I must remember, as Kate has pointed out, those things that are most important in my life. It’s so easy for me to get caught up working on various projects and typing on the keyboard late into the night. I’ve had to prioritize things and consciously remember what’s most important. I can always work more hours, treat more patients, be on another committee, have a conference call, write a book, and whatever other ego gratifying activities in the years to come. My relationships with my wife, children, and friends (and my health) are more important than any of those. I just need to be reminded of this every so often, but I’m working on it, so thanks for raising this important issue.
Ken Pope concludes:
I read the string that Jessica began with her question about the balancing act, and appreciated the diverse, thoughtful messages. Here are a few thoughts those messages evoked.It seems so important to raise these kinds of questions. To ask not only can I (or how can I) balance all these tasks but also how do all these tasks balance with what is most important to me, what brought me into the field, and what I want my life to be and to mean? It can be so easy to lose sight of original or deeper values when faced with so many competing demands in what Kate called the “treadmill to success”--with its image of running in place--and what Victor called “hell.” Something I’ve tried to do every year is sit down and evaluate the different things I’m doing and the different things I could be doing (with my time, my life, my resources) and make hard choices about what is most important to me. This has led to a lot of unexpected changes.Kate’s accident, in sending her message to this list rather than the other, seemed a real gift. Unfortunately there are many barriers to self-disclosure in our field. We’re all human, all make lots of mistakes, all sometimes feel confused, afraid, angry, discouraged, tired, incompetent, etc. But it is often hard to acknowledge this to our colleagues. The barriers seem to begin in graduate school, where the competitive model doesn’t encourage us to make ourselves vulnerable--If I talk about my weaknesses, will it affect what placements I get, will they appear in my letters of recommendation, etc.?--unless, of course, there is a competition to see who can create the most “open” image, in which case things can get pretty weird. Some graduate schools make persistent efforts to take down these barriers, but it is hard work. Back in the 80s, some colleagues and I used the subtitle “The Human Therapist and the (Sometimes) Inhuman Training System” for an American Psychologist article. Since the list’s beginnings, a number of you have written me back-channel about various matters and I’ve encouraged posting to this list a version of what you’d sent to me. I think that the more we can talk about what’s going on in our lives, our struggles, decisions, and dilemmas, the more the list can become a community in which people feel less alone, can speak honestly, can work on what’s important to them, can value both differences and commonalties. Thanks again to Jessica for starting that string and to all who have contributed.
Robin Belamaric asks:
I am wondering how other therapists have handled two inherent roles within the therapeutic relationship. On one hand, for the therapy itself, the therapist maintains a frame of keeping the client’s interests in the forefront (within the boundary of time), but the therapist also needs to collect payment, making the therapist’s own interests much more salient. How have other therapists handled it when money management is itself a therapeutic issue, or when clients stop paying their bill?
Marc Oster responds
I find this issue of money management - patient fees - an interesting one. It is a feature of a course I teach on professional practice. I’ve formulated my ideas from talking with many psychologists and seeing many therapists suffer with this problem.
I’ve found the money thing is much better managed when the therapist does several things:
- Whoever first speaks to the patient on the phone, sets the appointment, etc (in my case this is me) must, in an appropriate and sensitive manner, state, “And now I should let you know my (the doctor’s) fee is $120 per hour. I (the doctor) accept cash or checks at the time of service. I (s/he) do not send out monthly bills nor bill insurance companies.” This is followed by a moment of silence for the patient to consider what was just said and to respond. At that point you handle their reply as appropriate. This is of value because the caller knows before setting the appointment they are expected to pay when they come in and how much to pay. If this is understood in advance the caller either agrees or goes elsewhere. Now, you might ask, what if they can’t afford this arrangement (or whatever arrangement you offer) and don’t or won’t go elsewhere. You can always negotiate with them if you wish. I readily make fee arrangements and adjustments, including billing an insurance company (not a managed care company) if the referral source is a good source of mine, a friend or colleague, and a whole host of other potential exceptions. However, I do not offer special arrangements unless my referral source requests it or the patient expresses a concern.
- “I forgot my check book.” No problem. When I hand them their receipt, with the payment space left blank, I include a self-addressed envelope and ask that they mail the check so it arrives before our next appointment. This is all done in a very matter-of-fact manner.
- What if they forget the checkbook regularly or forget to mail the payment or bounce checks. Now we need to discuss these issues more directly. First, I do not permit a patient to carry a balance greater than 2-4 sessions. If we’re approaching that point, I ask about what’s happening in this regard. If the patient is having serious financial trouble I will not allow them to run up a balance in their hopes of paying it off later because that puts undue stress on our relationship and on them and it is seldom paid off after the therapy is completed. You can imagine that at our rates, balances increase pretty rapidly, by almost $500 per month. Instead, I see them for free until the situation improves. If they bounce checks, and I incur a fee from my bank, I ask they pay in cash the amount due plus any fees. If it happens more than twice, I ask to be paid in cash indefinitely. The only psychological type interpretations I make here has to do with confronting them with our relationship. “You come to see me to help you. I do and it appears you benefit from or appreciate what I do for you as you continue to come to my office. However, you fail to uphold your end of our agreement - paying your fee - and then put me, my family and my business, including my other patients at risk by not paying what you owe. This doesn’t sound like the kind of relationship either of us would want...”
- What about that 24 hour cancellation thing and the fee for failure to follow the rule?
I have found that many providers who indicate they have this cancellation policy don’t enforce it. They don’t ask for the late cancellation fee. My cancellation policy is simple. If you can’t make it, please call. Call and leave a message before the start of your appointment time. Since I’m usually in the office and have other work I could do, all I really need to know is if I should be standing around waiting for you or if I can take a dinner break. If you fail to call or call into your time, you bought that time.
I’ve known many therapists who report that they have no money issues. It is not a problem for them. What this usually means is that they have no money issues because they never talk about money with the patient. I’ve actually seen a client ask the therapist what their fee was and the therapist told them to discuss it with the receptionist. They have no issue with money because they never discuss sit nor touch it. Yes, I’ve known psychologists who mail out a monthly bill. Some patients would then arrive for their next appointment with a check. Seems reasonable, but this psychologist would REFUSE to accept the check - it’s their money! - and insisted the patient send the check by mail.
I’ve also known therapists who find themselves with large receivables and/or large amounts coming from insurance companies. Sometimes the claim is rejected and the therapist doesn’t ask the patient for the payment. I explain to my students and those to whom I consult that, in general, all our patients or clients are coming to us to get help in gaining some control over their lives and to live in a more responsible and healthy manner. Yet we fail to model this behavior by not following up with the person responsible for paying our fees, for our living - the patient. We try to help our patients to be healthier, yet we don’t take similar care of ourselves. Why should they listen to us when they sit there knowing they owe us money or bounced our check and aren’t paying us. They are stealing from us our livelihood and we say nothing. That’s not good for either the patient or us.
Do these policies or ideas sound too cold or mercenary and too money focused? Of course I don’t think so. I say that because if your basic office/practice policy or guidelines are discussed up front - usually on the phone, you seldom have to ever discuss them again nor enforce them. Indeed, I seldom have to enforce any of these policies. Sure, once in a while things come up that alter my arrangements with a patient, but when that happens, it’s addressed immediately so no one has to worry about it and it quickly becomes a non-issue. In this way, the money stuff interferes as little as possible with the ongoing therapy.
Is money always, to some degree or another, a clinical issue? Yes, it’s always a part of the therapy. This is true regardless if you’re in private practice (especially there) or working for a group or an agency.
Jeff Barnett adds:
I very much like Marc’s comments. He makes a number of great points. I agree that fees and financial arrangements are an integral part of the work we do. After all, we are providing a service and the patient is paying for it. All this is best addressed up front as Marc states and should be included in writing and reviewed verbally as part of the informed consent agreement. For many psychotherapists the topic of money is a very difficult one. After all, if we were really interested in making money, we would have gone into business. We became psychologists because we want to help people, not just to make money! But, being in practice is a business. We lease or own office space, hire staff, have insurance, phones, office supplies, furniture, and so on. If we don’t have sound business practices we won’t be able to stay in business. The goal is to have sound and realistic business practices that we are comfortable with, while at the same time developing a caring and helpful relationship with patients. And, as Marc implies, what kind of role models are we for our patients if we are uncomfortable, avoidant, and inconsistent? Actually, it is therapeutic to set clear and reasonable boundaries from the outset and to then stick with them. To not do so may be helping to perpetuate patterns of dysfunction for the patient (and us). Open discussions at the outset and then whenever issues arise are recommended. A signed written agreement is helpful as well when they ‘forget’ a previously agreed to arrangement. While providing free services to those who are unable to continue paying is very admirable, not all may be able to do this. Another option is to offer several additional sessions free or at a greatly reduced rate, and then during that time assist the patient to find a psychotherapist who accepts a sliding fee scale or refer them to a community health center or similar program. I hope this is of some help.
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Additionally, to submit questions for the authors to respond to directly, we may be contacted at barnetthome@erols.com and pymurph@SCIFAC.INDSTATE.EDU. The APAGS MENTORS listserv is a joint project of Division 42 and APAGS. We are indebted to Division 42’s Student and Young Professionals’ Committee chair, Pat Pitta, Ph.D. and APAGS Associate Executive Director, Carol Williams, M.A. for starting this exciting forum for students and psychologists to converse.